Provider Demographics
NPI:1083898597
Name:BRUNSON, WILSON ROBERT (LMFT)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:ROBERT
Last Name:BRUNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24525 OUTLOOK DR
Mailing Address - Street 2:A2
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-9466
Mailing Address - Country:US
Mailing Address - Phone:951-743-8385
Mailing Address - Fax:
Practice Address - Street 1:1290 NATIVIDAD AVE
Practice Address - Street 2:#200
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906
Practice Address - Country:US
Practice Address - Phone:831-755-4510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 22780106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC 22780OtherBOARD OF BEHAVIORAL SCIEN